Foundations of the HISTORY OF South African Heart Association: SA HEART® The South African Society of Cardiac Practitioners 1985 - 1999

Anthony J. Dalby EDITOR’S COMMENT

The South African Heart Association (SA Heart®) was Cardiologist, Life Hospital, Fourways, , established in 1999. Prior to 1999, 2 professional South Africa societies represented the interests of cardiologists and cardiac surgeons in South Africa – the South African Address for correspondence: Cardiac Society and the South African Society of Cardiac Practitioners. The latter was formed in 1985 Dr A.J. Dalby by cardiologists in private practice to serve the inter- Suite D46 Life Fourways Hospital ests of private practitioners. At the time, the South Cedar Avenue West African Cardiac Society was based mainly in the Fourways academic training institutions and the need arose to Johannesburg have a representative body addressing the needs of 2191 private practice. South Africa In the late 1990s it became clear that the 2 societies were competing for the same support from industry

Email: and were diluting each other’s infl uence. The realisa- tion that strength lay in unity led to an amalgamation [email protected] of the 2 societies in 1999 – to form the SA Heart® Association. In this commentary, Dr Tony Dalby provides us with a INTRODUCTION personal refl ection of the history of the South African In the early years, there were limited facilities for cardiologists Society of Cardiac Practitioners. In future issues of the SA Heart® Journal, we will feature similar personal and cardiac surgeons at institutions such as the Florence refl ections to document the history of the South Nightingale Hospital, Hospital Hill, Johannesburg. Cardiologists African Cardiac Society and the South African Heart in private practice often worked in close conjunction with Association. SAHeart 2018;15:214-216 academic and state institutions to obtain the more sophisti- cated aspects of care, such as echocardiography and cardiac catheterisation, for their patients. Cardiac surgery was almost nantly based in academic institutions, had neither an interest in the exclusive preserve of state hospitals at that time. However, nor the capacity to develop the required communications it was in the late 1970s that the development of cardiology between the professionals in private practice and the statutory and cardiac surgery in private practice took a significant step bodies. This void necessitated the establishment of a repre- forward with the establishment of Cardiac Catheterisation sentative organisation, which could give voice to the needs of Laboratories and Coronary and Cardiothoracic Intensive Care private practice. Units at private hospitals. The opening of these new facilities As a result, the South African Society of Cardiac Practitioners encouraged cardiologists and cardiac surgeons to move from (SASCP) was founded and its constitution, approved by their posts in state facilities into private practices situated in or MASA, was ratified at the Society’s first annual meeting held near these hospitals. Among the first units to open were Milpark Hospital in Johannesburg, City Park Hospital in Cape at the Royal Hotel, Durban, in November 1985. The first Town, and St Augustine’s Hospital in Durban. Executive Committee consisted of Dr MA Rogers (Chairman), Dr GA Cassel (Vice-Chairman), Dr CA Hammond (Secretary- Cardiac practitioners in private practice soon appreciated that Treasurer) and Drs J de Nobrega, EA Lloyd, and RM Matisonn. interactions with the medical aids, the Medical Association of The Society’s constitution was amended in 1988 to alter the South Africa (MASA), the South African Medical and Dental designation of the Chairman and Vice-Chairman to President Council (SAMDC), and the state, were required to facilitate and Vice-President, and furthermore to separate the roles of the coding of and allocation of tariffs to the new procedures the Honorary Secretary and Treasurer. The Presidents who being performed in private practice. The existing South African followed Dr Rogers were Dr GA Cassel, Dr EA Lloyd, Cardiac Society (SACS), a long standing organisation predomi- Dr RM Matisonn, and Dr AJ Dalby.

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The SASCP’s stated objectives were to promote the private with medical aids and a public relations subcommittee be practice of cardiology and cardiac surgery, to define and established. Despite several attempts at establishing this “busi- establish relationships among private cardiologists and private ness unit”, professionals investigating the option recognised Volume 15 Number 3 Volume 15 cardiac surgeons – and between those groups and hospitals, the difficulties in gaining consensus from this group of highly public and private institutions, government authorities and the individualistic doctors, as well as their poor appreciation of medical profession in general. In addition, an objective was to business skills. They appreciated that it would be necessary to promote the legitimate professional interests of private cardi- create a “common need” or to enhance levels of awareness ologists and private cardiac surgeons. of a “potential crisis”, in order to unify the disparate views of cardiac professionals. Any registered medical practitioner confining his practice to cardiology or cardiac surgery, or with a special interest in either discipline and who was a member of the MASA, was eligible MANAGED HEALTHCARE for membership. Around its peak in 1995, SASCP member- In 1996, Anglo-American and United HealthCare of America ship reached 170. combined to form Southern HealthCare JV, which intended to launch its initial managed healthcare programme in . From its inception until 1998, the major sponsorship was In effect, this company proposed a “top down” imposition of provided by Bristol Mead Johnson (later called Bristol Myers American-style managed healthcare. At the initial meeting held Squibb) through the good offices of Mr Quintin Oswald and in Rosebank, Johannesburg, attending practitioners were pro- later Dr B Allmann, Mr P van Hoesselen, Mr B Scott and others. vided with a rough outline of the organisation’s ambitions and Through the generous sponsorship provided, SASCP was also attendees were invited to pick up a contract which was ready able to fund the air travel of 1 or 2 of its members to attend to sign. However, subsequent attempts to obtain clarity from congresses overseas each year. Southern HealthCare on numerous issues failed to elicit satis- factory responses. Members were urged to not sign the prof- ANNUAL MEETINGS fered contract; 98% of members agreed. The first portion of The SASCP held annual meetings from 1985. With the growth the Annual General Meeting that year was a symposium to of the Society’s annual meeting and with the assent of BMS, discuss managed healthcare. Various presenters, including additional sponsorship was obtained from various pharma- Mr John Wardle of Southern Healthcare and the Society’s guest ceutical and medical device companies from 1991 that allowed Dr Richard Pozen of Vivra Heart Services, Florida, USA, parti- for a greater number of international speakers to be invited. In cipated. Mr Wardle’s brazen approach included him standing addition to the annual meetings, courses in coronary inter- with his foot on the front desk of the meeting hall, while vention were organised from time to time, to which international lecturing members. Following this performance, Dr Pozen experts were invited to demonstrate new techniques. remarked that he had then understood the meaning of the term “ugly American” for the first time.

COMMUNICATION With the emergence of managed healthcare in South Africa, In 1989 Prof AJ Brink independently established the Cardio- “doctor companies” were formed to unite various groups of vascular Journal of Southern Africa, which became the mouth- professionals in their response to the imposition of the pro- piece for the Southern African Cardiac Society, and the South posed measures. In 1997, the development of a “Cardiologists’ African Society of Cardiac Practitioners. Two years later, the Company” was explored, eventuating in the formation of Society commenced the publication of an independent news- CARAPACE Co-operative, which attracted 126 members. letter to update its members on the Society’s activities. However, by 1998 the initial proposals of managed health- care companies to contract outright with medical practitioners CARDIAC BUSINESS UNIT began fading away, once it became apparent that the principle In November 1989, the Society organised a “Think Tank” under of “divide and rule” by offering preferred provider status would the auspices of Bristol Myers, enabling cardiologists and cardiac not succeed within a small, overworked medical community surgeons from around the country to interact directly with not seeking individual preferment with a view to increasing their representatives of medical schemes, private hospitals and the patient numbers. Around this time, the author was treated to pharmaceutical industry. Arising from this meeting, it was lunch by Dr J Jersky, an employee of Southern HealthCare JV. proposed that a business unit be developed to represent His message was brief: “You have beaten us this time, but it cardiac practitioners, and that a subcommittee to deal directly won’t happen again”. Not long after this the funders began

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imposing mechanisms such as pre-authorisation and central CLINICAL TRIALS drug lists upon their members, without entering into contracts From 1995, an informal sub-group of members began voluntary with practitioners. The usefulness of CARAPACE fell away and participation in international Phase 3 clinical trials in cardiology the Co-operative was closed down in 2000. Remnant funds variously investigating fibrinolysis, antiplatelet therapies, dyslipi- were transferred to the South African Heart Association. daemia, heart failure, and atrial fibrillation.

RELATIONSHIPS WITH OTHER BODIES SUB-GROUP DEVELOPMENT The Society was in regular communication with MASA, the In the last decade of the century, the specific interests of SAMDC, the Department of Health, the Heart Foundation of paediatric cardiologists, electrophysiologists and interventional South Africa, the Alliance of Consulting Clinical Disciplines, and cardiologists led to the independent development of special the Health Technology Policy Committee. Members of the interest groups, which were loosely allied to the SASCP. Executive dealt with coding of procedures and tariffs such as Holter monitoring, coronary angiography, paediatric cardiology, AMALGAMATION post-operative care following cardiac surgery, and over-ser- At the AGM in 1995, a proposal to amalgamate the SASCP vicing. The Society gained increasing recognition as the mouth- and SACS was put forward, but rejected by a majority vote. piece for cardiology and cardiac surgery and was frequently By June 1997, the impracticality of having 2 societies within consulted by the SAMDC (from 1997 called the Health Pro- South Africa representing a community of cardiac profes- fessionals Council of South Africa) and the MASA when con- sionals totalling less than 200 came to be recognised and a tentious issues arose. After the SASCP and others protested written proposal for a merger of the SASCP and SACS was put at the lack of an increase in the scale of benefits for specialists forward. Furthermore, despite still providing generous sponsor- in 1990, the MASA held a conference at Helderfontein in April ship of the SASCP, a broad spectrum of pharmaceutical and to discuss the apportionment of tariffs, for instance between device companies were encountering increasing difficulty in labour-intensive and capital-insensitive services, intra- and funding both the SASCP and SACS. Furthermore, though inter-disciplinary relativities, and the avoidance of over-servicing. separated by a thin line, it was realised that the influence of Resulting from the Helderfontein Conference, the MASA both Societies was being diluted by their joint existence. Once Fees Committee was restructured as the Private Practice Com- the Societies acknowledged the need for amalgamation, a mittee (PPC) to which Dr J Benjamin and Dr CA Hammond constitution for the new body was devised under the direction were seconded. In 1991, PPC adjusted the cardiovascular tariff of Prof P Manga and Prof O von Oppel of SACS and Dr structure with the help of Dr J Benjamin. AJ Dalby and Dr S Spilkin representing the SASCP. The pro- posed constitution was circulated to the members of both Over the years, the Society was requested to comment on Societies. Written comment was received and incorporated matters such as a proposed Social Health Insurance Scheme, before the final version was circulated and voted upon; 47% of undergraduate medical education and training, continued SASCP members responded, returning a 95% vote in favour of medical education, the registration for Continued Professional amalgamation. Both Societies were dissolved and the South Development, health technology policy, the Tobacco Products African Heart Association (SA Heart®) was established. The last Amendment Act, euthenasia and assisted suicide, and the Annual General Meeting of the SASCP was held in conjunction Department of Health’s threatened closure of heart trans- with the 1st Annual General Meeting of SA Heart® at Fancourt, plant units. near George, in September 1999. Eight invited overseas guests addressed the meeting, which was sponsored by 22 companies. The SASCP also made inputs into MASA’s national guidelines on lipids, heart failure, cardiac rehabilitation, and conscious The new Association’s constitution made provision for a sedation. National Executive, 4 Standing Committees (Education, Ethics and Guidelines, Private Practice, and Full-Time Service Practice), TRAINING Regional Branches, Specialty Groups (Cardiothoracic Surgery, In 1989, the SASCP proposed the establishment of satellite Paediatric Cardiology) and Special Interest Groups (e.g. the training units at both Milpark Hospital and the Morningside Cardiac Arrhythmia Society of South Africa [CASSA] and Clinic for cardiology and cardiac surgical registrars training the South Africa Society for Cardiac Intervention [SASCI]). through the University of the Witwatersrand. The university Prof AF Doubell was elected SA Heart®’s first President and rejected these suggestions and nothing came of them. Prof PJ Commerford as Vice-President.

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